WORKER’S COMPENSATION BOARD OF INDIANA STATE FORM 18488 9R13/3-990
402 WEST WASHINGTON STREET, ROOM W196 FORM SI-1 (Revised 2017)
INDIANAPOLIS, IN 462042753 Approved by State Board of Accounts
www.in.gov/wcb
WORKER'S COMPENSATION AND OCCUPATIONAL DISEASES ACTS
EMPLOYER'S APPLICATION FOR PERMISSION TO
CARRY RISK WITHOUT INSURANCE
This application is for employers subject to the provisions of the "Indiana Worker's Compensation and Occupational Diseases Acts", that wish to obtain a certificate to pay compensation directly, without insurance, to injured employees or to the dependents of employees who die as a consequence of illness or injury as a result of a workplace injury. This also covers payment of medical expenses incurred in the treatment of an injured worker.
This application will cover the period of September 1, 2017 to midnight, August 31, 2018. The information provided herein is for the purpose of enabling the Worker's Compensation Board of Indiana to determine whether the applicant possesses sufficient financial ability to render certain the payment of such compensation and medical expenses. Applicant Employer, through ______, ______, who
(name) (position within organization)
is qualified to speak on behalf of and bind the named applicant, under the penalties of perjury, hereby states the following facts:
1. EMPLOYER INFORMATION
______New Applicant ______Renewal Applicant
Applicant Name: ______
Address: ______
______
______
Nature of Business: ______
______
Website Address: ______
FEIN: ______
2. SUBSIDIARY INFORMATION
Indiana Location(s) Kind of Employment # of Employees
a. ______
b. ______
c. ______
d. ______
e. ______
SUBSIDIARIES INCLUDED UNDER SELF-INSURANCE AUTHORITY
FEIN # TITLE NAME CONTACT INFORMATION
a. ______
b. ______
c. ______
d. ______
e. ______
3. LOSS HISTORY
Please submit relevant Loss Run Reports electronically on a flash drive or a disc, with the information set out on the following chart.
Under Amount Paid, please provide the total paid for each calendar year, regardless of the date of injury. Under # of Injuries, please provide the number of injuries which occurred during the calendar year indicated.
2014 / 2015 / 2016Amount Pd / # Injuries / Amount Pd / # Injuries / Amount Pd / # Injuries
Medical
TTD
TPD
PTD
PPI
Death Benefits
Burial Expenses
Settlements
First Report of Injury
Amputation
Prosthetic Device
TOTAL / $ / $ / $
4. BOND CALCULATION
(a) Determine threeyear average of total medical/compensation paid per
"Loss History"
2014 Total Paid $______
2015 Total Paid + $______
2016 Total Paid + $______
ThreeYear Total Paid $______divided by 3 = $______
3yr average
(b) Multiply 3 year average by 2 $______
(c) Enter greater of $500,000 or line (b) $______
(d) Increase/decrease in line (b) from prior year $______
(Additional security required)
5. SECURITY
a. SURETY BOND
Amount of Bond $ ______Cost of Bond $ ______(Required)
($500,000.00 Minimum) (Annual Premium)
Surety Name: ______Telephone:______
Address: ______
Bond # ______(Application cannot be processed if blank)
Please provide a copy of the Bond herewith.
and/or b. LETTER OF CREDIT – please attach a copy
Amount of LOC $______Name of Financial Institution ______
Routing Number ______Identification # of LOC ______
c. EXCESS COVERAGE:
Specific $______SelfInsured Retention $ ______
Aggregate $______Cost of Excess $______(Required)
(Annual Premium)
d. Does the employer have a system to establish a reserve to pay claims for medical treatment or compensation? ______
e. List other states, if any, in which the employer is selfinsured
______
6. SELFINSURANCE ADMINISTRATION
It is the obligation of the employer to timely advise the Board of any changes in the information provided below which occur during the selfinsured period. Please note that the Board now sends all notices related to Self-Insurance via email and would prefer email notices from employers as well.
(a) Identify the person within the employer's organization who is primarily responsible for the selfinsurance program. This person will receive all notices as it relates to the self-insurance program, please list an alternative if you would like two individuals to receive notices:
Name: ______
EMail: ______
Address: ______
Telephone: ______
Fax: ______
Alternative:
Name: ______
EMail: ______
Address: ______
Telephone: ______
Fax: ______
(b) Identify the person(s) who is primarily responsible for the adjustment of Indiana employee claims made pursuant of the selfinsurance program (within your company or at your thirdparty administrator):
Name: ______
EMail: ______
Address: ______
Telephone: ______
Fax: ______
Number of years of experience in the adjustment of worker's compensation and occupational disease claims in Indiana: ______
Describe educational training in Indiana Worker’s Compensation Law: ______
Has this individual attended at least one seminar on Indiana Worker’s Compensation over the past year? ______
This is mandatory, which course ______, ______, ______
Name Location Date
(c) Identify the person who is primarily responsible to receive hearing notices and other official communications from the Worker's Compensation Board regarding Indiana disputed claims:
Name: ______
EMail: ______
Address: ______
Telephone: ______
Fax: ______
(d) All companies who carry risk without insurance must file first reports of injury electronically according to standards prescribed by the Board. Please indicate whether the applicant is able to comply with this mandate.
______Yes _____ No _____ A copy of the approved plan is attached.
7. ATTACHMENTS
All applicants must attach the following items to this application:
_____ (a) An audited financial statement signed by an officer of the employer, such statement to become part of this application. A copy of the employer's last annual report to its stockholders may be accepted in lieu of a financial statement, if prepared within the last six (6) months. This information shall be treated as confidential by the Board and used only in evaluating this application. It will not be provided to any other entity.
_____ (b) Loss runs from the prior 3 years to verify the information provided in the Loss History and Bond Calculation sections of the application. Detailed loss information is included, specifically claimants name and total payment amounts. Please submit electronically or on a disc/flash drive.
_____ (c) Information concerning involvement or membership in organizations or seminars specifically directed toward selfinsured workers compensation issues. Is your company a member of Indiana Self-Insured Association? Yes ____ No ____
_____ (d) Additional information concerning the knowledge of the Act, education and claims experience of the person responsible for receiving notices from injured employees, and the amount of time this person devotes to the workers compensation process (if selfadministered).
_____ (e) Please provide information regarding training that those individuals responsible for the administration of self-insurance, have received in the past year regarding Indiana worker’s compensation administration, laws, regulations, or other.
_____ (f) Copy of bond, LOC or other form of security approved by the Board.
Additionally, new applicants must attach the following information:
_____ (i) Premium payments made the last three years and to which carrier(s).
_____ (iii) NCCI experience modification for the last three years.
_____ (iv) Audited financial statements, as described above, for the past three years.
_____ (v) Administrative costs anticipated in association with selfinsuring, particularly if the applicant intends to utilize a thirdparty administrator.
8. CONDITIONS
The applicant hereby expressly understands and agrees as follows:
a. This privilege may be revoked at any time at the discretion of the Worker's Compensation Board of Indiana ("Board").
b. Applicant shall fully discharge, by immediately negotiable instrument or approved debit card, payment of all installments of compensation for disability or impairment promptly when due, as well as liability for physician's fees, hospital services, hospital supplies, and/or burial.
c. If the Board so requires, following a determination of Permanent Total Disability by agreement or award, the applicant shall demonstrate within thirty (30) days after this determination continuing liability to pay compensation to an injured employee for a definite period for a permanent injury (or to the dependents of a deceased employee) by making a special deposit, with a bank or trust company within the State of Indiana approved by the Board, in an amount set by the Board. Such special deposit to be made upon such terms as are prescribed by the Board.
d. Applicant shall promptly notify the Board of any change in condition which could ultimately affect its ability to pay medical expenses or compensation or administer its selfinsurance program.
e. Applicant shall discharge all amounts due for statutory assessments under the Acts.
f. Applicant shall furnish and file with the Board any security agreement, surety bond, indemnity agreement, Letter of Credit, and/or excess insurance coverage, which may be required as a condition for approval of this application.
g. Applicant, upon approval by the Board, recognizes, understands and agrees that in all cases the total assets of the applicant and its subsidiaries, if any, are pledged and available for the payment of any valid compensation or occupational disease claims made pursuant to Indiana law.
h. Applicant understands that if its surety bond is canceled and no replacement bond is simultaneously filed with the Board, its selfinsured status shall terminate upon the effective date of the bond cancellation without further notice from the Board and Applicant shall immediately purchase a Worker’s Compensation insurance policy.
i. Applicant understands and agrees that the surety posted will not be released until all possibility of additional losses has terminated and the Worker’s Compensation Board has approved the bond’s release, but in no event will the bond’s release be granted prior to three years from the last date of self-insurance.
j. Applicant understands and agrees that the surety bond posted will not be reduced until a minimum of two years from the last date of self-insurance and that the decision to reduce the bond is in the sole discretion of the Board and will be based upon currently active claims and claims that have been closed within the two years prior to the date of the request for reduction of the bond.
The statements made herein are true and accurate to the best information and knowledge of the undersigned and are made for the express purpose of inducing the Worker's Compensation Board of Indiana to grant the Applicant selfinsured status as allowed by IC 22351.
This application is executed at______this ______day of
______,______.
FOR THE APPLICANT:
______
(Company)
BY:______
(Signature)
______
(Printed Name)
TITLE______TELEPHONE NUMBER:______
(Must be an Officer of Applicant)
FOR BOARD USE ONLY:
______APPROVED ______DENIED
COMMENTS: ______
______
______
DATED: ______
WORKERS COMPENSATION BOARD OF INDIANA
______
BY: Linda Peterson Hamilton, Chairman
Application Type / Amount Due / Payment InformationNew application / $500.00
Renewal Application / $250.00
Late: filed after 7/31/17 or incomplete renewal application
PLEASE PAY ELECTRONICALLY VIA http://www.in.gov/wcb/2516.htm